Understanding Patient Perspectives Toward Shared Decision-Making in Patients With Pulmonary Hypertension.

Clinical guidelines for pulmonary hypertension (PH) recommend shared decision-making and individualized treatment. However, patient perspectives on PH treatment goals, preference toward a decision-making style of treatment, and adoption of shared decision-making remain unclear. This cross-sectional questionnaire-based study assessed the patients' preferred and actual participation role in treatment decision-making, rated on 5 scales (ranging from passive [patients leave all decisions to physicians] to active [patients make the decision after physicians show patients several options]) and evaluated the concordance between preferred and actual participation roles. The important factors underlying patients' perspectives in treatment decision-making (i.e., prognosis; symptom, financial, family, and social burdens; patient values; and physician recommendation) were evaluated. Univariate logistic regression analysis was performed to determine the patients with a positive preference toward "physician recommendation" in treatment decision-making. Among 130 patients with PH (median age: 58 years; mean pulmonary arterial pressure: 23 mm Hg; 27.7% were males), 59.2% preferred that "physicians make the decision regarding treatment after showing patients therapeutic options (i.e., intermediate between passive and active roles)." The patient-preferred and actual participation roles in decision-making had moderate agreement (Cohen's kappa = 0.46). The most important factor in treatment decisions was "symptom burden reduction" (93.8%). Although 85.0% of patients chose "physician recommendation" as an important factor, 49.6% chose "alignment with my values." The determinants of patients who chose "physician recommendation" were less severe hemodynamics and better functional capacity. In conclusion, patients with PH preferred that the "physicians make the decision after showing patients therapeutic options" and prioritized physician recommendation over their values.

Predicting readmission for heart failure patients by echocardiographic assessment of elevated left atrial pressure.

BACKGROUND: Pathophysiologically, an elevated left ventricular (LV) filling pressure is the major reason for heart failure (HF) readmission. The 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines provide a simplified algorithm for the echocardiographic assessment of LV filling pressure; however, this algorithm is yet to be sufficiently validated. MATERIALS AND METHODS: We retrospectively studied 139 consecutive patients with acute decompensated HF. High estimated left atrial pressure (eLAP) was defined according to the 2016 ASE/EACVI guidelines. Univariate and multivariate logistic regression analyses were performed to identify significant risk factors for HF readmission within one year of discharge. RESULTS: Across the study cohort, 68 patients (49%) did not have a high eLAP, 32 (23%) had an indeterminate eLAP, and 39 (28%) had a high eLAP. The number of HF readmission events within one year in the without high eLAP, indeterminate, and high eLAP groups were 4 (7.5%), 5 (18.5%), and 10 (33.3%), respectively. The HF readmission rate was significantly higher in patients with high eLAP than in those without high eLAP. Multivariate analysis revealed high eLAP (odds ratio, 5.924; 95% confidence interval, 1.664-21.087; P = 0.006) as a significant risk factor for HF readmission within one year. Furthermore, the exploratory analysis of the two-year outcomes revealed a similar finding: patients with high eLAP had a significantly higher rate of readmission for HF. CONCLUSIONS: The present study demonstrated that echocardiographic assessment of elevated LAP based on the 2016 ASE/EACVI guidelines is clinically valid for predicting readmission in patients with HF.

Investigating the implant position reproducibility of optical impressions obtained using an intraoral scanner and 3D-printed models fabricated using an intraoral scanner.

PURPOSE: This study aims to examine the effect of the size of the intraoral scanning area on implant position reproducibility and compare the implant position reproducibility of plaster models fabricated using the silicone impression technique, the digital model of an intraoral scanner, and three-dimensional (3D)-printed models fabricated using an intraoral scanner. METHODS: Scanbodies were attached to an edentulous model with six implants (master model) and were scanned using a dental laboratory scanner to obtain basic data. The plaster model was fabricated using the open-tray method (IMPM; n = 5). The master model was then scanned in various implant areas using an intraoral scanner to obtain data (IOSM; n = 5); the scanning data of six scanbodies were used to fabricate the 3D-printed models (3DPM; n = 5) using a 3D printer. Scanbodies were attached to the implant analogs of the IMPM and 3DPM models and data were obtained using a dental laboratory scanner. The basic data and IMPM, IOSM, and 3DPM data were superimposed to calculate the concordance rate of the scanbodies. RESULTS: The concordance rate of intraoral scanning decreased as the number of scanbodies increased. Significant differences were observed between the IMPM and IOSM data, and between the IOSM and 3DPM data; however, the IMPM and 3DPM data did not differ significantly. CONCLUSIONS: The implant position reproducibility of the intraoral scanner decreased with an increase in the scanning area. However, ISOM and 3DPM may provide higher implant position reproducibility than plaster models fabricated using IMPM.

Right Atrial Appendage Thrombus in a Patient Undergoing Thoracoscopic Left Atrial Appendectomy for Atrial Fibrillation.

Left atrial appendage (LAA) closure may prevent atrial fibrillation (AF)-induced thromboembolism. We describe a rare case of right atrial (RA) thrombus after thoracoscopic left atrial appendectomy and pulmonary vein isolation. Careful evaluation for the presence of RA thrombus in patients with persistent AF after LAA occlusion may be necessary. (Level of Difficulty: Intermediate.).

Successful epoprostenol withdrawal and termination with an aid of the exercise stress test in pulmonary arterial hypertension.

Continuous infusion of intravenous epoprostenol (EPO) improves exercise capacity and survival in pulmonary arterial hypertension (PAH); however, it is associated with side effects. This study aimed to describe our experience on safe EPO withdrawal with the aid of an exercise stress test. This retrospective review included patients with PAH who were successfully withdrawn from EPO. Haemodynamic data were obtained before EPO administration, at withdrawal, and after discontinuation. After the mean pulmonary arterial pressure (mPAP) decreased to <25 mmHg for at least 1 year, an exercise test under right heart catheterisation was performed. If exercise pulmonary hypertension was not record (mPAP - cardiac output slope < 3), EPO was withdrawn. Of the 99 patients who received EPO, ten were identified as having undergone withdrawal or termination. mPAP decreased from 61 (54-71) mmHg before treatment to 19 (17-21) mmHg before withdrawal and remained unchanged, at 19 (14-23) mmHg, 1 year after EPO discontinuation. After a median follow-up of 32 months, all the patients survived. Patients with PAH who recovered their normal haemodynamic function were safely withdrawn from EPO with the aid of an exercise stress test.

Novel diagnostic and therapeutic approaches to pulmonary hypertension due to the unilateral absence of a pulmonary artery.

We report the case of a 64-year-old female diagnosed with severe pulmonary hypertension due to the unilateral absence of a pulmonary artery. The four-dimensional computed tomography scan is a useful modality for revealing detailed anatomical findings for differential diagnoses and surgical decision-making. The patient had severe pulmonary hypertension with a mean pulmonary artery pressure (PAP) of 74 mmHg and was treated with triple upfront combination therapy, leading to significant improvement in pulmonary haemodynamics (to 27 mmHg in mean PAP) and functional capacity (WHO functional class, from III to II; 6-min walk distance, from 211 to 276 m).